Healthcare Provider Details

I. General information

NPI: 1760406151
Provider Name (Legal Business Name): ANN J LARSEN DDS, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10350 BANDERA RD STE 122
SAN ANTONIO TX
78250-5616
US

IV. Provider business mailing address

10350 BANDERA RD STE 122
SAN ANTONIO TX
78250-5616
US

V. Phone/Fax

Practice location:
  • Phone: 210-256-9767
  • Fax:
Mailing address:
  • Phone: 210-256-9767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number14947
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: